Pediatric emergency medicine trisk 1339 1339
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dermatitis, candida diaper dermatitis, and mixed dermatitis. Acrodermatitis
enteropathica, which is caused by zinc deficiency, psoriasis, and Langerhans cell
histiocytosis, should also be considered in the differential diagnosis for diaper
dermatitis that is persistent or does not respond to antifungals and antiinflammatory medications.
Treatment is determined by the cause of the dermatitis. In general, optimized
skin care, which includes decreased frequency of washing, use of mild soaps, and
use of barrier emollients, will help with any diaper dermatitis. With occlusive
dermatitis, avoidance of tightly fitting diapers, plastic-covered paper diapers, and
rubber pants is important. When atopic dermatitis is present, the use of topical
steroids is necessary. It is important to avoid fluorinated or other potent steroids
in the diaper area because occlusion by the diaper enhances the steroid effect and
is more likely to produce skin atrophy and striae. Antifungal–steroid
combinations should also be avoided for these same reasons. Therefore, 1% or
2.5% hydrocortisone cream or ointment no more than twice daily over a short
period (5 to 7 days) is recommended. Hydrocortisone (1% or 2.5%) is also
effective for seborrheic diaper dermatitis and can be used intermittently. With
candidal diaper dermatitis, the use of preparations such as econazole, miconazole,
or nystatin twice daily is effective. If thrush is also present, oral nystatin
suspension, 200,000 units (2 mL) four times a day for 7 days, is advisable. This
medication will also be useful if the infant is seeding C. albicans from the GI
tract onto the skin of the diaper area. Secondarily infected dermatitis, such as
bullous impetigo, should be treated with the appropriate systemic antibiotics or in
some cases topical antibiotics.
Atrophic Patches
Aplasia Cutis
Aplasia cutis is a congenital defect that is characterized by localized absence of
epidermis and dermis and, sometimes, subcutaneous fat. It generally occurs on
the scalp (80% near the hair whorl) but can occur on any location of the body.
Right after birth, aplasia cutis can appear as a scar or as a weeping, granulating
oval or circular defect. Small defects are the most common but larger ones
sometimes occur and may extend to the dura or meninges. Some lesions may
present with an almost bullous appearance and when surrounded by dark hair or
thicker hair (hair collar sign) may represent a form of neural tube defect. Patients
with these lesions should undergo an MRI of the brain to look for underlying
connection to the brain. Congenital absence of skin can also be seen with
